


































GSJP Volume 16 final


100

Graduate Student Journal of  Psychology
2015, Vol. 16

Copyright 2015 by the Department of  Counseling and Clinical Psychology
Teachers College, Columbia University

100

Rewriting History: Attachment Theory in the 
Practice of  Adult Psychotherapy

Jillian D. Farrell, B.A.
Department of  Counseling and Clinical Psychology

Teachers College, Columbia University

Jacqueline A. Carleton, PhD
National Institute for the Psychotherapies

Attachment theory can enhance both the therapist’s and patient’s awareness of  their roles in the psychothera-
peutic process, their effect on the therapeutic alliance, and their understanding of  themselves and one an-
other. John Bowlby (1980) proposed that the innate developmental task of  infants is to seek and grow a rela-
tionship with their primary caregiver, offering the child protection and security (Dolan et al., 1993; Farber 
et al., 1995; Levy, 2005; Sable, 2007). As an adult, the acquired pattern of  attachment behavior guides how an 
individual relates to others, functions in interpersonal situations and relationships, regulates emotions, and re-
ÁHFWV� RQ� SDVW� RU� SUHVHQW� DWWDFKPHQWV� �$WNLQVRQ� HW� DO��� ������ 0LNXOLQFHU� HW� DO��� ������ 6DEOH�� ������ =LOFKD� HW�
DO��� ������� %\� UHYLHZLQJ� WKH� VHOHFWHG� OLWHUDWXUH� LQ� WKH� ÀHOG�� WKH� SUHVHQW� DUWLFOH� VWULYHV� WR� KHOS� FOLQLFLDQV� GHHSHQ�
their understanding of  the role of  attachment theory with adult patients, in the psychotherapeutic process, 
as it has been elaborated in the recent literature. It is hoped that clinicians will be inspired to follow up with 
some of  the multitudinous references we have provided to this fascinating literature. We would also hope that 
they realize that a great deal of  evidence has accrued of  the effectiveness of  attachment based psychotherapy.

Introduction

Background 
 John Bowlby (1980), the father of  attachment 
theory, established a conceptual framework that con-
tinues to inspire attention and research. The princi-
ples of  the theory address the innate developmental 
task of  infants to seek and grow a relationship with 
their primary caregiver, offering the child protection 
and security (Sable, 2007; Levy, 2005; Dolan et al., 
1993; Farber et al., 1995). This is congruent with the 
ethological principle that all mammals require the 
SUHVHQFH�RI �D�FDUHJLYLQJ�ÀJXUH�DV�WKH�SURWHFWRU�RI �WKH�
fragile infant striving for survival (Bernier et al., 2002; 
Bowlby, 1980; Diener et al., 2011; Muller, 2009). Us-
ing Bowlby’s theory as a foundation, Mary Ainsworth 
went on to systematically assess attachment needs and 
behaviors of  toddlers in her well-known experiment, 
The Strange Situation (Ainsworth, 1985; Ainsworth 
et al., 1978). From there, Mary Main and colleagues 
developed the Adult Attachment Interview (AAI), 
enabling researchers and clinicians to explore at-
tachment related phenomena in late adolescence and 
adulthood (Wallin, 2007). An enormous amount of  
DWWDFKPHQW�UHVHDUFK�FRQWLQXHV�WR�ÁRXULVK�DQG�WKHUH�LV�
now substantial empirical support for Bowlby’s (1980) 

conviction that early family experience is related to lat-
er personality functioning (Harris, 2004; Sable, 2007). 
 The present paper strives to help clinicians deepen 
their understanding of  the role of  attachment theory 
in the psychotherapeutic process with adult patients, 
as it has been elaborated in the plethora of  recent 
OLWHUDWXUH��%\�UHYLHZLQJ�VHOHFWHG�OLWHUDWXUH�LQ�WKH�ÀHOG��
knowledge and perspectives of  attachment concepts 
are examined and integrated to form a comprehen-
sive overview. The various elements of  attachment 
theory are discussed in the context of  psychotherapy, 
including suggestions for the application of  theory to 
practice and possible directions for future research. 

6LJQLÀFDQFH�RI �$WWDFKPHQW�7KHRU\�LQ�&OLQLFDO�
Practice
 The phrase “attachment state of  mind” denotes 
the way an individual in adulthood processes at-
tachment-related cognitions, feelings, and memories 
(Atkinson et al., 2004). Attachment systems impact 
people’s trust in close relationships, their fears of  re-
jection, their weak or intense yearning for intimacy, 
and their tendency to favor dependency or autono-
my (Meyer et al., 2001). The acquired pattern of  at-
tachment behavior guides how he or she relates to 
others, functions in interpersonal situations and re-
ODWLRQVKLSV�� UHJXODWHV�HPRWLRQV�� DQG� UHÁHFWV�RQ�SDVW�
or present attachments (Atkinson et al., 2004; Mi-Keywords: attachment, psychotherapy, working alliance, AAI



101

kulincer et al., 2007; Sable, 2007; Zilcha et al., 2011). 
Indeed, attachment theory offers a foundation from 
which a clinician can better understand the limitations 
and capacities of  an adult patient through the consid-
eration of  childhood and current relationships that 
have brought about the person’s representations of  
the self  and others (Sable, 2007; Smith et al., 2009).
 Utilizing attachment theory, an adult patient’s ca-
pacity to form positive relationships can be examined 
(Smith et al., 2009). In adults, psychopathology may 
arise from or result in the inability to form and main-
tain close relationships (Sable, 2007). Additionally, 
attachment theory can be understood as a theory of  
trauma in which the lack of  and/or disruption in se-
cure connections to others generates traumatic stress 
DQG�PRGLÀHG�VW\OHV�RI �DWWDFKPHQW��/HY\���������$Q�
individual’s attachment system is associated with the 
capacity for intersubjectivity, affect-regulation, men-
talization, and other developmental processes; thus, 
the disruption or weakness of  these processes due 
to a maladaptive attachment system can weigh heav-
ily on one’s functioning and be manifested in symp-
toms (Bowlby, 1980; Sable, 2007). Lamagna (in press) 
states, “This ‘internal attachment system’, compris-
ing states representing our subjective experience and 
VWDWHV� UHÁHFWLQJ� RQ� DQG� DSSUDLVLQJ� WKDW� H[SHULHQFH�
coordinates its activity in ways that best regulate the 
individual’s affects, thoughts, perceptions, and behav-
ior.” Research shows a convincing connection be-
WZHHQ�DWWDFKPHQW�GHÀFLWV�DQG�$[LV�,�DQG�$[LV�,,�GL-
agnoses (Shorey et al., 2006). Bowlby (1980) pointed 
out long ago that separations, losses, and other distur-
bances in attachment are the foundations from which 
emotional distress and personality disorders arise. 

How Attachment Theory Is Related to Psycho-
pathology in Adulthood
 Wallin (2007) proposes that the guiding rules of  a 
person’s life are those evolved from the “rules of  attach-
ment” that were internalized and embedded in infancy 
through interactions with caregivers. These “rules”, in 
WLPH��GHÀQH�WKH�PHDQV�E\�ZKLFK�RQH�DFFHVVHV�DWWDFK-
ment-related cognitions, emotions, and recollections. 
The attachment they had as infants has been found 
to be strongly linked to their psychological health 
as adults (Atkinson et al., 2004; Shorey et al., 2006).

 The individuals typically exhibiting psychopa-
thology are unable to protect themselves against 
and/or cope with threats, stresses of  human in-
teraction, and the hassles of  everyday life due to 
WKH� DEVHQFH� RI � WKH� ÁH[LEOH� SV\FKRORJLFDO� SURFHVV-
es developed through early attachment experienc-
es (Bateman et al., 2003; Bowlby, 1980; Levy, 2005; 
Sable, 2007; Zilcha et al., 2011). Losses and unre-
solved experiences in a person’s attachment system 
can be kept hidden in a dissociated state that only 
releases these overwhelming experiences when pro-
voked with cues relating to them (Wallin, 2007). 
 
7KH�0RGLÀFDWLRQ�RI �$WWDFKPHQW�6\VWHPV�LQ�
Psychotherapy
 Fortunately, attachment systems can be mod-
LÀHG� E\� VXEVHTXHQW� UHODWLRQVKLSV�� RQH� RI � ZKLFK� LV�
psychotherapy (Mikulincer et al., 2007; Wallin, 2007; 
Zilcha et al., 2011). The experience of  psychother-
DS\�� ÀUVW� GHVFULEHG� E\� )UHXG� DV� ´WKH� WDONLQJ� FXUHµ��
generally involves self-disclosure of  concerns by 
the client and facilitation of  change by the therapist 
(Leger, 1998). Vaughn and Burgoon (1976) noted, 
“Parsons (1951) maintains that therapy becomes 
necessary when the control mechanisms inherent 
in the reciprocities of  ordinary human relationships 
break down” (p.256, quoted from Leger, 1998). Thus, 
psychotherapy, particularly attachment-focused psy-
chotherapy, has the potential to transform the rigid 
processes of  one’s attachment system to become 
more robust, as well as re-write the way a person 
views him or her self  and others (Harris, 2004).
 The growing research in attachment is beginning 
to facilitate greater application of  the theory to the 
practice of  psychotherapy (Mikulincer et al., 2007; 
Wallin, 2007). Findings have supported the notion 
that clinicians’ knowledge of  attachment theory en-
KDQFHV� WKH� HIÀFDF\� RI � WKH� WKHUDSHXWLF� UHODWLRQVKLS�
(Farber et el., 1995). Psychotherapeutic treatment uti-
lizing attachment theory provides an opportunity for 
a patient to delve into both early and current attach-
ment experiences while in a safe setting and with a 
safe person: the therapist (Bowlby, 1980; Sable, 2007). 
Attachment theory can “enrich (rather than dictate) 
the therapist’s understanding of  his or her patient” 
(Steele et al., 2008), allowing the therapeutic alliance 

FARRELL, CARLETON



102

and intervention techniques to be designed to match a 
SDWLHQW·V�VSHFLÀF�QHHGV��0DOOLQFNURGW�HW�DO�����������

Developmental Processes Starting In  
Early Attachment Experiences 

Internal Working Models of  Attachment
 Internal working models are the foundations of  
adaptive or maladaptive thoughts and behaviors (Zil-
cha et al., 2011). An individual’s unique internal rep-
UHVHQWDWLRQV� VWURQJO\� LQÁXHQFH�KLV� RU�KHU�EHKDYLRUV�
and security later on in life (Bowlby, 1980; Cortina et 
al., 2003; Harris, 2004; Lamagna, in press; Levy, 2005; 
Smith et al., 2009; Zilcha et al., 2011). These internal 
working models are organized behavioral systems and 
cognitive structures developed through the internal-
ization of  early interactions with caregivers and the 
environment (Bowlby, 1980; Cortina et al., 2003; Die-
ner et al., 2011; Harris, 2004; Levy, 2005; Meyer et al., 
2001; Mikulincer et al., 2007; Sable, 2007; Zilcha et al., 
2011). Once these representations of  self  and others 
are formed, one’s expectations and style of  thinking 
are virtually automatically implemented in subsequent 
relationships (Diener et al., 2011; Muller, 2009). The 
meaning of  events is constructed to be congruent 
with the inner working models, whether accurate or 
inaccurate. Negative internal working models lead to 
the misinterpretation of  social cues, like attributing 
hostility to others’ benign intentions (Muller, 2009). 
In other words, as a child matures through life his 
or her internal expectations, established from early 
experiences, govern the experience and navigation 
of  the external world (Harris, 2004; Leger, 1998).  
 The propositions of  both Bowlby (1980) and in-
terpersonal theorists suggest that an essential goal of  
therapy is the restructuring of  representations of  ear-
ly attachment interactions and the transformation of  
insecure internal working models and destructive re-
lational behaviors (Diener et al., 2011). These changes 
are thought to occur as a result of  the new relationship 
experiences with the therapist (Diener et al., 2011). 
Although initially clients’ negative working models 
LQÁXHQFH�KLV�KHU�DWWDFKPHQW�DQG�SHUFHSWLRQV�RI �WKH�
therapist, they become more secure during the course 
of  therapy as the client is subjected to the consistency 
and responsiveness of  the therapist (Bowlby, 1980; 

Mallinckrodt et al., 2005; Smith et al., 2009). For ex-
ample, clients with a dismissing attachment style may 
be cold and unwelcoming towards the therapist at the 
RQVHW�RI �WKHUDS\��PDNLQJ�LW�GLIÀFXOW�WR�KDYH�D�FRQYHU-
sation. After they experience the warmth and helpful-
ness of  the therapist at a carefully titrated pace, these 
clients begin to feel more motivated and comfortable 
sharing with the therapist and interacting in sessions.
 Through the internalization of  the therapist 
DV� D� QXUWXULQJ� DQG� UHOLDEOH� ÀJXUH�� D� FOLHQW� JUDGXDOO\�
builds an internal working model of  the therapist 
DQG�FRPHV�WR�VHH�WKH�WKHUDSLVW�DV�DQ�DWWDFKPHQW�ÀJ-
ure that he or she can resort to during distress, at 
ÀUVW� WKURXJK�GLUHFW� FRQWDFW� DQG�HYHQWXDOO\�E\� LQWHU-
nalization (Bowlby, 1980; Farber et al., 1995). The 
evocation of  the therapist by the client during emo-
WLRQDO� DQG�RU� LQWHUSHUVRQDO� GLIÀFXOW\� DOORZV� IRU� WKH�
employment of  affect regulation strategies and the 
revision of  maladaptive expectations and behaviors 
(Obegi, 2008). The changes in reaction to stressful 
circumstances and the experience of  a positive at-
tachment relationship contribute to an increased 
FRQÀGHQFH�LQ�WKH�VHOI �DQG�RU�RWKHUV��2EHJL��������
 The internalization of  the benevolent role of  
the therapist and the formation of  a positive in-
ternal working model of  the therapist is critical to 
therapeutic change (Zilcha et al., 2011). Clients can 
reveal their internal working models through attach-
ment behaviors, transference, narratives, and self-re-
ports (Harris, 2004). In the case of  transference, the 
patient actually projects his or her internal working 
models onto the therapist (Smith et al, 2009). Trans-
ference can include positive manifestations that prog-
ress treatment forward, or negative manifestations 
that may be seen as resistance (Cortina et al., 2003).  
 Dozier and Tyrell (1998) stressed the need for the 
therapist to gently challenge the client’s attachment 
patterns, assumptions about relationships, and coping 
strategies in order to encourage the steady exploration 
of  emotional and interpersonal issues. The goal is to 
restructure the models to be more congruent with ac-
curate and current knowledge and experiences (Sable, 
2007).  Dozier and Tyrell (1998) termed this process 
a “correctional experience”. In adult patients, there is 
an unconscious, active adherence to the preexisting 
´UXOHV�RI �DWWDFKPHQWµ��7KHUHIRUH��GLVFRQÀUPLQJ�WKH�

ATTACHMENT IN PSYCHOTHERAPY



103

client’s internal working models propels the client to 
investigate, reevaluate, and understand past experi-
ences that have shaped his/her problematic models 
and representations (Eagle et al., 2006; Shorey et al., 
2006). Some label this type of  intervention involving 
a push for change as  “purposeful misattunement” 
(Shapiro et al., 1999). From this exploration, expec-
tations and perceptions of  the self  and/or relation-
ships can be revised and internal working models 
FDQ�EH�UHFRQÀJXUHG��=LOFKD�HW�DO����������$V�+ROPHV�
(2000) describes, this restructuring of  working mod-
els is like “story-making” and “story-breaking”. The 
internal world of  the adult patient is reassembled in a 
way that allows a more coherent narrative of  the self  
to be formed, as well as the events of  one’s life to 
“fall into place” (Sable, 2007). With regard to attach-
ment, it is the discovery of  meaning in our personal 
KLVWRU\� WKDW� LQÁXHQFHV� WKH� VHFXULW\� RI � RXU� VWDWH� RI �
mind, rather than the actual content of  this history.
 Attachment and interpersonal theorists agree that 
a therapist’s noncomplementary response to a client’s 
attachment tendencies promotes an opportunity for a 
client’s internal working models (also called “interper-
sonal complementary hypothesis”) to be challenged 
and revised (Bernier et al., 2002; Goodman, 2010). 
%\�ÁH[LEO\�WDNLQJ�RQ�D�FRQWUDVWLQJ�VWDQFH�WR�WKH�FOL-
ent’s rigid assumptions, no reinforcement is given to 
WKH� FOLHQW·V� LQÁH[LEOH� LQWHUSHUVRQDO� RULHQWDWLRQ� DQG�
there is an opportunity for the client to explore alter-
native expectations of  the self  and/or relationships. 
For example, a therapist treating a dismissing patient 
QHHGV�WR�VORZO\�HQFRXUDJH�UHÁHFWLRQ�RQ�WKH�SDWLHQW·V�
emotional issues he/she is trying to ignore, rather 
than allowing these issues to be overlooked (Bernier 
et al., 2002). On the other hand, a therapist working 
with a preoccupied patient, who is pouring out his/
her emotional issues and is clinging to the therapist, 
must gradually encourage autonomy (Bernier et al., 
2002). If  the therapist gives in to every demand and 
need of  the preoccupied patient, the individual’s in-
ternal working model of  the self  will only become 
more enmeshed with his/her relationships and the 
negative attachment behaviors will be reinforced.  
 The security of  the therapist’s own attachment 
system, which will be discussed below, contributes 
to his or her capacity to adapt to the needs of  the 

client. In some cases, it is extremely challenging or 
impossible for a therapist to provide the patient 
with the sense of  security needed to establish the 
restorative positive relationship with the therapist 
(Mallinckrodt et al., 1995; Zilcha et al., 2011). If  
this is the case, the patient may be able, guided by 
the therapist, to use a current intimate relationship.

Mentalization and Attachment Style
 Mentalization is the ability to understand hu-
man action in the context of  one’s underlying mental 
representations (Bateman et al., 2003). The capac-
ity for mentalization is the foundation of  a stable 
structure of  the self  and is developed through ear-
ly attachment and subsequent social experiences 
(Gergely et al., 1996). Disorganized and/or weak 
early attachments can become incorporated into the 
self-structure resulting in the experience of  oneself  
and others in this maladaptive, disoriented mode. In 
adults, there is an unconscious, active adherence to 
the preexisting “rules of  attachment” based on these 
assumptions. With an unstable sense of  self, the in-
dividual inherently strives to defend their distorted 
and schematic perceptions of  self, others, and rela-
WLRQVKLSV�DJDLQVW�WKUHDWV�WKDW�PD\�FRQÁLFW�ZLWK�WKHVH�
perceptions, perhaps through aggressive impulses 
or mental isolation (Bateman et al., 2003).  This re-
GXFHG�FDSDFLW\�WR�PHQWDOL]H�FDQ�EH�UHÁHFWHG�LQ�SRRU�
interpersonal relations, maladaptive and insecure as-
sumptions about oneself, and emotional volatility. 
 In psychotherapy, the issues of  mentalization can 
be addressed and improved (Bonovitz, 2010). The 
therapist can help cultivate a patient’s capacity for 
PHQWDOL]DWLRQ�E\�FRQVLVWHQWO\�TXHVWLRQLQJ�DQG�UHÁHFW-
ing on the internal states within the patient (and with-
in the therapist) characterizing the current moment 
(Bateman et al., 2003). The mutual exploration allows 
the therapist to discover links between external and 
internal experiences that seem incomprehensible for 
WKH�SDWLHQW��%DWHPDQ�HW�DO����������7KLV�FODULÀFDWLRQ�DO-
lows the patient to become aware and make sense of  
previously ambiguous feelings about oneself, others, 
and relationships (Bateman et al., 2003). The argu-
ment is that feelings are re-experienced and released 
during the psychotherapeutic process as one repro-
cesses past experiences. This allows for the patient 

FARRELL, CARLETON



104

to organize a more accurate construction of  experi-
ence and restructure the self  (Leger, 1998). Conse-
quently, this new understanding and sense of  control 
over one’s internal states facilitates mentalization.

Internal Working Models of  Patients Based On 
Attachment Style
 It is critical for the therapist to understand the 
nature of  the internal working models each patient 
brings into treatment. Individuals with a secure attach-
ment style hold assumptions that are both practical 
DQG�EHQHÀFLDO�IRU�WKHLU�LQWHUQDO�ZHOOEHLQJ�DQG�VRFLDO�
experiences. Their internal working models sustain 
a trust in the goodness and competence of  the self  
DQG�RWKHUV��DV�ZHOO�DV�D�GHVLUH�IRU�DQG�D�FRQÀGHQFH�LQ�
relationships (Bordin, 1979; Diener et al., 2011; Levy, 
2005). Individuals with a secure attachment are less 
restricted by internal rule-based patterning, enabling 
WKHP�WR�EH�ÁH[LEOH�LQ�WKHLU�LQWHUSHUVRQDO�FRPPXQLFD-
tions (Wallin, 2007). This internalized positive inner 
working model facilitates a higher tolerance for anxi-
ety, especially in novel experiences, resulting in a great-
er freedom to explore the world and a more coherent 
integration of  experiences (Mallinckrodt et al., 2005). 
They have overall better functioning in areas such as 
impulse control, empathy, and marital relations (Levy, 
2005; Main et al., 1986). A more secure attachment 
LV�EHQHÀFLDO� IRU� WKH� W\SH�RI �PHQWDOL]DWLRQ� WKDW�SHU-
PLWV� WKH� HIÀFDF\� RI � LQWURVSHFWLRQ� WKDW� FDQ� GLVFORVH�
DQG�HYDOXDWH�DWWDFKPHQW�LQÁXHQFHV�RQ�RQH·V�UHODWLRQ-
ship functioning and affect regulation (Obegi, 2008). 
 In contrast, an insecure attachment style consists 
of  internal working models that have a negative, am-
biguous, and mistrusting view of  the self  and others 
(Diener, et al., 2011). Inadequate early caregiving ex-
periences encode in the memory attachment interac-
tions that are inconsistent (Sable, 2007). The dissoci-
ated representations of  attachment, hypothesized by 
Main as “multiple models” of  attachment, are similar 
to Freud’s ideas regarding the dynamic unconscious. 
Instead of  the unlimited access to attachment-related 
information present within secure individuals, those 
with “multiple models” are governed by rigidity in 
what they are supposed to know and feel rather than 
being able to use the entirety of  their experiences 
(particularly those that are threatening).  Therefore, 

an insecurely attached individual may feel discomfort 
with closeness in relationships and/or anxiety in times 
of  separation (Wallin, 2007). The negative internal 
working models of  the self  and/or other fuel distress 
GXH� WR� WKH� LQVXIÀFLHQW� GHYHORSPHQW� RI � DSSURSULDWH�
physiologic and affect regulation as a result of  poor 
early caregiving experiences. In these cases, attach-
ment repair must precede introspective exploration.

Categorization of  Attachment Patterns
 In regards to childhood attachment, sever-
al different categorization schemes have been 
proposed consisting of  different labels and 
numbers of  categories. For the sake of  simplic-
ity, in this piece, I will focus on the categories pro-
posed by Ainsworth (1978) and Main et al (1986).
Their work yielded four patterns of  attachment: se-
cure, insecure-ambivalent, insecure-avoidant, and dis-
organized (Dolan et al., 1993; Hietanen et al., 2006). 
Children’s attachment styles are highly correlated with 
similar attachment patterns in adulthood. There are 
also children with attachment styles deemed “cannot 
classify” since a clear pattern of  attachment does not 
present itself  in the assessment. But, for most, place-
ment into one of  the four styles of  attachments is 
possible. A caretaker may be nurturing and responsive, 
promoting the child’s development of  a sense of  se-
curity and secure attachment (Levy, 2005; Pally, 2001). 
On the contrary, inadequate early caregiving experi-
ences could hinder processes like attaining the ability 
to self-regulate, as well as result in unstable attach-
ment thoughts and insecure attachment (Sable, 2007).  
For adults, the attachment styles are conceptualized 
as: secure-autonomous, preoccupied, dismissing, or 
unresolved/disorganized  (Hietanen et al., 2006).

$VVHVVLQJ�$WWDFKPHQW�6W\OH�	�7KH�$GXOW� 
$WWDFKPHQW�,QWHUYLHZ��$$,�

 As previously described, an infant’s early attach-
ments to caregivers are internalized forming cogni-
tive-affective structures (Bowlby, 1980) that evolve 
into similar models in adulthood and are active in 
one’s current emotional and relational involvements. 
The concept of  adult attachment styles refers to in-
dividuals’ comfort and position in close relationships, 

ATTACHMENT IN PSYCHOTHERAPY



105

their tendency to favor autonomy or dependency, 
as well as their anxiety regarding rejection and in-
accessibility in relationships (Ainsworth et al., 1978; 
Meyer et al., 2001). For an attachment-informed psy-
chotherapist, the initial assessment focuses on the 
quality of  the potential client’s relationships (Cor-
tina et al., 2003). A central part of  the assessment 
will be the history of  primary caregivers’ respon-
siveness or inattentiveness, especially noting wheth-
er the client experienced a loss of  or abandonment 
by a caregiver, and the subsequent attachment style 
the client developed (Cortina et al., 2003). Attach-
ment style can usually be adequately assessed with-
out the complete implementation of  a validated in-
strument; however, a tool like the Adult Attachment 
Interview (AAI) is very useful (Cortina et al., 2003). 
 The Adult Attachment interview (AAI) is the 
most accepted interview method of  assessing adult 
attachment measures; however, self-report question-
naires can also be used to measure attachment patterns 
(Eagle, 2006). The AAI, formulated by Mary Main 
and her colleagues, involves an hour-long interview 
in which an adult self-reports behaviors in intimate 
relationships and narrates experiences in childhood 
concerning early relationships with his or her parents 
(Bernier et al., 2002). This process unveils the per-
son’s “states of  mind regarding attachment” (Harris, 
2004) and “autobiographical competence” (Holmes, 
1995). Of  primary importance, is the coherency of  
the narrative one relates about childhood experiences 
and relations. The clinician’s task is to listen to the pa-
WLHQW·V�VWRU\��WU\�WR�ÀQG�PHDQLQJ�ZLWKLQ�LW��DQG�XQFRY-
er the clues in the story that underlie the attachment 
pattern (Holmes, 1995). With treatment, the therapist 
and client can work jointly in re-writing the client’s 
narrative (Holmes, 1995). As the psychotherapeutic 
process unfolds, change and improvement can be 
DVVHVVHG�E\�WKH�FXOWLYDWLRQ�RI �D�PRUH�ÁRZLQJ��FRP-
prehensible, and expressive story (Holmes, 1995).  
 It is important to note the AAI’s focus on child-
hood omits insight from some relevant relationships, 
such as those with siblings, marital partners, and co-
workers (Cortina et al., 2003). The optimal means of  
assessment may be for the clinician to use the AAI 
with other measures or questions (Cortina et al., 
2003). A measure like the Attachment Style Inter-

view (ASI) may be a valuable supplement given that 
it concentrates on the aspects and coherence of  one’s 
narrative, but also addresses the entire range of  adult 
relationships (Cortina et al., 2003). There are also 
some measures that use a multi-item continuous scale 
(Smith et al., 2009), such as the Experiences in Close 
Relationship Scale (ECRS; Brennan et al., 1998) and 
the Adult Attachment Inventory (AAI; Simpson et 
al., 1992). These measures evaluate anxiety and avoid-
ance, with lower scores on both dimensions indicating 
a more secure attachment pattern (Smith et al., 2009).
 The three insecure attachment styles discussed 
above are the result of  poor and/or inadequate early 
attachment relationships. Individuals possessing these 
attachment styles often suffer problems in emotional 
control and serious psychological distress that con-
tribute to their anxiety, depression, hostility, and mal-
adaptive patterns in interpersonal relations (Bachelor 
et al., 2010). Anderson and Perris (2000) performed 
two studies to assess the relationship between adult 
attachment styles and dysfunctional working mod-
els using the AAI, the Attachment Styles Question-
naire (ASQ), and the Dysfunctional Working Models 
6FDOH� �':0�6��� 7KH\� IRXQG� VWDWLVWLFDOO\� VLJQLÀFDQW�
correlations supporting their hypotheses that secure 
attachment is negatively associated with dysfunc-
tional assumption scores and insecure attachment is 
positively associated with dysfunctional assumptions. 
Consequently, individuals with insecure attachments 
have a greater need to piece together experiences 
that have caused the dysfunctional working models 
increasing distress and symptomology (Sable, 2007). 
  Cortina and Marrone (2003) present a chart 
matching attachment style and type of  prior caregiv-
er with the related issues involving the creation of  
a supportive therapeutic alliance and potential solu-
tions. For example, a client who is fearful of  rejec-
WLRQ�LV�SDLUHG�ZLWK�D�SUHYLRXV�FDUHJLYLQJ�ÀJXUH�WKDW�LV�
consistently rejecting and/or unresponsive to needs 
(Cortina et al., 2003).  An issue in therapy may be 
the client’s avoidance of  talking about his or her ac-
tual concerns and needs since there is a fear that do-
ing so will lead to rejection (Cortina et al., 2003). To 
address this issue, the therapist must focus on con-
veying the non-judgmental context of  therapy and 
the therapeutic relationship (Cortina et al., 2003). 

FARRELL, CARLETON



106

The table provided by Cortina & Marrone (2003) 
LQFRUSRUDWHV�WKH�DXJPHQWHG�FODVVLÀFDWLRQ�RI �DWWDFK-
ment styles used by Bifulco and colleagues (2002) 
as a guide to help the development of  the alliance. 
However, a plausible concern for using attachment 
measures in a clinical setting is: if  the patient is clas-
VLÀHG�DV�KDYLQJ�D�FHUWDLQ�DWWDFKPHQW�VW\OH��LV�WKHUH�D�
greater likelihood therapists will misinterpret experi-
ences with a patient and establish their views based 
RQ� WKH� SDWLHQW·V� LQLWLDO� DWWDFKPHQW� FODVVLÀFDWLRQ"�
 Daly and Mallinckrodt (2009) interviewed expe-
rienced therapists about approaches they found ef-
fective for clients with particular attachment styles. 
Therapists reported the importance of  gradually 
increasing the therapeutic distance with anxiously 
attached clients (Daly et al., 2009). Conversely, the 
therapists suggested a gradual decrease in therapeutic 
distance for avoidant patients (Daly et al., 2009). In 
addition to guiding the therapist’s approach for the 
patient, awareness of  the patient’s attachment history 
prepares the therapist for the types of  transference 
experiences that may occur, as well as improves the 
therapist’s understanding of  his or her own possi-
ble countertransference reactions (Shilkret, 2005). 
There are different manifestations of  transference 
that patients can display, which may vary through-
out treatment (Goodman, 2010). Interestingly, Freud 
(1912, 1913) discussed the dynamic of  transference 
involved in psychotherapy: the unconscious negative 
component, the unconscious positive component, 
and the conscious “unobjectionable” component 
�*RRGPDQ�� ������� 7KH� ÀUVW� WZR� VHUYH� DV� RSSRVL-
tions to treatment, while the latter represents feel-
ings of  value towards treatment and facilitates suc-
cess in treatment (Goodman, 2010). Moreover, he 
LGHQWLÀHG� WKH� SDWLHQW·V� DWWDFKPHQW� WR� WKH� WKHUDSLVW�
as a requirement for the occurrence of  unobjec-
tionable transference, which facilitates the devel-
opment of  the working alliance (Goodman, 2010).

The “Working Alliance” in Attachment-Focused 
Therapy with Adults

 Attachment theory and research shed enormous 
light on both the client’s and therapist’s internal 
ZRUNLQJ�PRGHOV�LQÁXHQFLQJ�WKH�SURJUHVVLRQ�RI �WKHU-

apeutic process, especially with regard to the creation 
of  the working alliance (or client-therapist alliance) 
(Hietanen et al., 2006; Smith et al., 2009). Greenson 
�������ZDV�WKH�ÀUVW�WR�XVH�WKH�WHUP�́ ZRUNLQJ�DOOLDQFHµ�
(Diener et al., 2011; Horvath et al., 1991), which he 
GHÀQHG� DV� D� ´UDWLRQDO� UHODWLRQVKLS� EHWZHHQ� SDWLHQW�
DQG�DQDO\VWµ��S��������&RQVLGHULQJ�WKH�KHDY\�LQÁXHQFH�
of  the attachment styles of  both the therapist and 
of  the patient on the formation of  the alliance, Bor-
din  (1979) views the alliance as “dyadic and mutual 
with the therapist and client as active co-constructors, 
constantly negotiating and renegotiating the alliance 
in order for successful work to take place” (Bordin, 
1979; Smith et al., 2009). When it comes to the actu-
al “alliance”, Bordin (1979) hypothesized the alliance 
to consist of  three facets: the goal, the task, and the 
bond (Diener et al., 2011; Hietanen et al., 2006; Smith 
et al, 2009). The goal and the task involve the cogni-
WLYH� HOHPHQWV� RI � WKH� DOOLDQFH�� VSHFLÀFDOO\� WKH� DJUHH-
ment on the general objectives of  treatment and the 
particular actions that will be employed to achieve 
the set goals (Bordin, 1979; Hietanen et al., 2006). 
The bond, the emotional and relational component, 
involves all the affective experiences that enables cli-
ent to develop an attachment to the therapist, such 
as the client’s feelings of  trust and empathy (Bordin, 
1979; Hietanen et al., 2006). It is the attachment to 
the therapist that allows the client to participate in 
the tasks and achieve the goals (Smith et al., 2009). 
The opportunity for therapeutic change occurs with 
the therapist and client attending to and repairing ob-
stacles resulting from a disagreement about one or 
more of  the three components (Smith et al., 2009). 
Since times of  danger or distress both activate attach-
ment systems and often bring clients to therapy, re-
searchers have come to link the concept of  the ther-
apeutic alliance with attachment theory (Farber et al., 
1995; Harris, 2004; Sable, 2007; Smith et al., 2009).  
 Research has found that a stronger alliance is asso-
ciated with less distress in psychotherapy as treatment 
progresses (Sauer, 2010; Smith et al., 2009). In con-
trast, the failure to develop an alliance can bring about 
a premature termination of  therapy (Harris, 2004). 
Horvath and Greenberg (1986) developed the Work-
ing Alliance Inventory (WAI) to measure this work-
ing alliance, which includes the three subscales (task, 

ATTACHMENT IN PSYCHOTHERAPY



107

goal, and bond) (Goodman, 2010; Smith et al., 2009).

The Therapist As A Secure Base 
 The therapeutic relationship is more than a bond; 
it is also an attachment (Obegi, 2008; Zilcha et al., 
2011). The relationship incorporates characteristics 
of  child-caregiver relationships, such as the reassuring 
presence of  the therapist and the possibility for emo-
tion regulation ( Goodman, 2010; Meyer et al, 2001). 
First, the child must come to see the caregiver as a 
UHOLDEOH�DWWDFKPHQW�ÀJXUH�WKDW�KH�RU�VKH�FDQ�WXUQ�WR�
if  threatened or distressed, making them a safe haven 
(Eagle, 2006). Through experiences of  an encouraging 
DQG�DYDLODEOH�DWWDFKPHQW�ÀJXUH��WKH�FKLOG�WKHQ�FDQ�XVH�
the caregiver as a secure base that provides the com-
IRUW�DQG�FRQÀGHQFH�D�FKLOG�QHHGV�WR�EH�PRWLYDWHG�WR�
explore the world (Ainsworth et al., 1978;  ,1980; Ea-
gle, 2006; Farber et al., 1995; Lamagna, in press; Levy, 
2005; Lipton & Fosha, 2011; Mikulincer et al., 2007). 
 Similar to the caregiver-infant relationship, Bowl-
by (1980) proposes the therapist serve as a secure 
base from which the patient can safely explore dif-
ÀFXOW�SV\FKRORJLFDO�PDWWHUV�UHODWLQJ�WR�ERWK�LQWHUQDO�
and external factors (Dozier et al., 2004; Eagle et al., 
2009; Farber et al., 1995; Goodman, 2010; Holmes, 
1995; Meyer et al., 2001; Schauenburg et al., 2010; 
=LOFKD�HW�DO����������$V�D�UHFHSWLYH�ÀJXUH��WKH�WKHUDSLVW�
accepts the client’s feelings, offers emotional avail-
ability, and provides regulated affect, which allows 
for the development of  attachment (Malinckrodt et 
al., 1995; Mikulincer et al., 2007; Sable, 2007). The 
positive attachment relationship with the therapist 
IDFLOLWDWHV� WKH� FOLHQW·V� FRQÀGHQFH� LQ� KLV� RU� KHU� RZQ�
DELOLWLHV�DQG�LQ�WKH�FDSDFLW\�WR�KDYH�IXOÀOOLQJ�UHODWLRQ-
al experiences (Sable, 2007). Therapists’ empathetic 
presence combined with the mastery they project 
embeds a base that a patient feels comfortable using 
WR� YHQWXUH� LQWR� GLIÀFXOW� WHUULWRULHV� �+ROPHV�� ������
� %\� UHÁHFWLQJ� RQ� SDVW� OLIH� H[SHULHQFHV� DQG� HDUO\�
attachment relationships with the help and support 
of  therapists, patients can give meaning to past ex-
SHULHQFHV�DQG�H[SORUH�WKH�LQÁXHQFH�WKH\�KDG�DQG�RU�
have on their distress and functioning (Sable, 2007). 
The availability of  the therapist during exploration 
facilitates the change needed for the client to explore 
DQG�PDNH�PRGLÀFDWLRQV�WR�KLV�RU�KHU�FXUUHQW�FRJQL-

tions, feelings, and behaviors (Eagle et al., 2009; Ma-
honey, 1990, paraphrased from Leger, 1998; Sable, 
2007). This transformation towards a stable, coherent 
self-representation is not possible in psychotherapy 
without the therapist’s fundamental role as a “secure 
base” (Bowlby, 1980; Eagle et al., 2009; Farber et al., 
1995). The empathy of  the therapist, the security of  
the client-therapist relationship, and the safe intimate 
space are needed for the patient to obtain the free-
dom to think and feel without the fear that his or her 
unstable or fragile self  will be threatened or attacked.
 In addition to the therapist’s function as a secure 
base within the therapeutic setting, the patient can 
utilize the representations of  the therapist developed 
through attachment, even after the termination of  
therapy, during times of  stress in order to gain that 
sense of  comfort and competence that allowed for 
problem solving during treatment, as well as to ex-
plore new opportunities and relationships (Farber et 
al., 1995). The evocation of  the therapist’s internal 
working model (discussed above during emotional 
and/or interpersonal strain can even help the indi-
vidual regulate affect and change the way he or she 
approaches the stressful situation (Eagle et al., 2009; 
Obegi, 2008). The new strategies for dealing with 
VWUHVV� DQG� UHODWLRQVKLSV� UHÁHFW� D� SRVLWLYH� WUDQVIRU-
mation in the client’s internal working models and 
attachment security (Eagle et al., 2009). The client’s 
LQFUHDVHG� FDSDFLW\� IRU� UHÁHFWLYH� IXQFWLRQLQJ� SHU-
mits the construction of  a more coherent narrative, 
ZKLFK�LV�OHVV�DPELJXRXV�DQG�FRQÁLFWLQJ��(DJOH�HW�DO���
2009). Lipton and Fosha (2011) propose, “through 
meta-therapeutic processing, or metaprocessing for 
short, the secure attachment relationship between 
patient and therapist becomes the vehicle through 
which a patient’s right-brain experiencing of  psycho-
therapy is integrated with her left-brain, conscious, 
verbal knowing that a therapeutic experience has just 
occurred” (p. 271). The resulting clarity in one’s nar-
UDWLYH�DQG�WKH�LPSURYHPHQW�RI �UHÁHFWLYH�IXQFWLRQLQJ�
foster a sense of  security and stability in the view 
of  not only oneself, but also in the view of  others.  

The Alliance As A Predictor of  Therapeutic 
Outcome
 Research has indicated that the quality of  the 

FARRELL, CARLETON



108

early working alliance and the nature of  the thera-
pist as a secure base is crucial to the therapeutic out-
come (Diener et al., 2011; Harris, 2004; Horvath et 
al., 1991; Meyer et al., 2001; Mikulincer et al, 2007; 
Sauer et al., 2010; Schauenburg et al., 2010; Smith et 
al., 2009). Byrd et al. (2010) studied the impact of  
the working alliance on the patient’s attachment style 
during treatment, as well as the impact of  the attach-
ment style on the psychotherapeutic process. Results 
showed that two attachment dimensions (Comfort 
with Closeness and Comfort Depending on Others) 
were positively related to the alliance and treatment 
RXWFRPH�� $GGLWLRQDOO\�� WKH� DOOLDQFH� LQÁXHQFHG� WKH�
dimension Comfort with Closeness, which, in turn, 
promoted more successful therapeutic outcome. 
 It has also been proposed that therapists’ per-
ceptions of  the therapeutic alliance depend on the 
attachment style of  the client, while the client’s per-
ception of  the therapeutic alliance was not related to 
attachment style (Dolan et al., 1993; Horvath et al., 
1986). Therapists reported a stronger therapeutic al-
liance with secure patients and a weaker alliance with 
patients that had a more avoidant attachment (Dolan 
et al., 1993). A meta-analytic review investigated past 
research exploring the relationship between client at-
tachment and the therapeutic alliance, which consist 
of  two categories of  client attachment, clients’ glob-
DO� DWWDFKPHQW� SDWWHUQV� DQG� FOLHQWV·� VSHFLÀF� DWWDFK-
ment pattern to their therapist (Smith et al., 2009). 
The theoretical literature indicates that with regard 
to patients’ global attachment, clients’ secure attach-
ment yields a stronger therapeutic alliance (Diener et 
al., 2011; Mikulincer et al., 2007; Smith et al, 2009). 
Similarly, those who perceive themselves as secure-
ly attached to their therapist develop stronger ther-
apeutic alliances (Smith et al., 2009). On the other 
hand, clients with an avoidant-fearful attachment 
pattern experience a less positive therapeutic alli-
ance (Smith et al., 2009) Comparing the two catego-
ries, evidence supports that the client’s attachment 
to therapist has a greater impact on the therapeutic 
alliance than the client’s global attachment (Smith 
HW� DO��� ������� 3HUKDSV�PHDVXULQJ� FOLHQWV·� VSHFLÀF� DW-
tachment may be more valuable than measuring cli-
ents’ global attachment when interested in predicting 
the quality of  the therapeutic alliance (Smith et al., 

2009). Dolan et al. (1993) also propose that perhaps 
more research should be done on whether therapists’ 
modify their interpersonal stance and intervention 
strategies based on the client’s attachment style and 
how the therapist perceives the therapeutic alliance.
 Studies investigating the working alliance rela-
tionship have primarily focused on clients’ individual 
pretreatment characteristics, such as motivation and 
sociability (Horvath et al., 1986; Smith et al., 2009). 
Clients’ internal working models determine their per-
ceptions of  the therapist and the client-therapist re-
lationship (Bowlby, 1980; Dozier et al., 2004; Eames 
et al., 2000; Smith et al., 2009; Zilcha et al., 2011). 
Especially when working with insecurely attached 
patients, knowledge of  patients’ attachment histo-
ries can provide the therapist with insight that can 
help them predict potential ruptures in the alliance; 
therefore, they can be proactive in their methods for 
intervening (Diener et al, 2011; Shorey et al., 2006). 
5HFRJQL]LQJ� WKH� VLJQLÀFDQFH� RI � DWWDFKPHQW� H[SHUL-
ences in the therapeutic relationship, Mallinckrodt, 
Gantt, and Coble (1995) created the Client Attach-
ment to Therapist Scale (CATS) (Sauer et al., 2010). 
The measure contains three subscales similar to at-
WDFKPHQW�VW\OH�FODVVLÀFDWLRQV��6HFXUH��$YRLGDQW�)HDU-
ful, and Preoccupied-Merger (Sauer et al., 2010). A 
study investigating the relationship between attach-
ment and the early therapeutic alliance reported that 
preoccupied attachment in patients predicted more 
frequency in ruptures, whereas dismissing attach-
ment was associated with fewer ruptures (Eames et 
al., 2000).  Attachment theory can facilitate the build-
ing and maintenance of  the therapeutic alliance that 
endows a client with a perception of  safety and a 
motivation for deep exploration, and, thus, the pos-
sibility for a positive therapeutic outcome and a re-
duction in symptomology (Mallinckrodt et al., 2005).

The Patient’s Attachment Style

The Secure Patient
 During the AAI, adults with secure attachments 
convey coherent narratives that integrate past experi-
ences in a relatively balanced manner (Mallinckrodt et 
al., 2005). These individuals most likely do not have 
picture-perfect childhoods, yet they can understand 

ATTACHMENT IN PSYCHOTHERAPY



109

DQG� UHÁHFW� RQ� SDVW� HDUO\� DWWDFKPHQW� UHODWLRQVKLSV��
whether they were positive or negative (Sable, 2007). 
Lipton and Fosha (2011) suggest, “Several decades of  
research on the moment-to-moment (and even milli-
second-to-millisecond) interactions between moth-
ers and their babies tells us that reiterative, ongoing 
cycles of  attunement, disruption and repair in the 
context of  emotional experiencing are the essential 
building blocks of  secure attachment”(p. 258; Bee-
be et al., 2002). This type of  security in attachment 
LV�QHFHVVDU\�IRU�WKH�VHOI�UHÁHFWLYH�PHQWDOL]DWLRQ�WKDW�
supports introspection and metacognition (Mallinck-
rodt et al., 2005). With the ability to examine cur-
rent and past experiences in a constructive fashion, 
an adult can develop a more balanced approach and 
appraisal of  relationships, as well as better strategies 
for resolving thoughts, memories, and feelings that 
are related to distress (Sable, 2007). Thus, attachment 
VHFXULW\� VWURQJO\� LQÁXHQFHV� IXQFWLRQLQJ� LQ� LQWHUSHU-
sonal relations, the capacity for affect regulation, and 
psychopathology in adulthood (Atkinson et al., 2004 
Obegi, 2008). A person assessed as having a secure 
attachment will be more willing to self-disclose in-
formation about him- or herself  in psychotherapy 
(Atkinson et al., 2004; Mikulincer et al., 2007). There-
fore, the formation of  an emotional bond between 
therapist and patient would most likely be an easier 
and quicker process than with those patients lacking a 
secure attachment (Bordin, 1979; Smith et al., 2009). 

The Preoccupied Patient
 Among those assessed to have an attachment 
VW\OH�WKDW�LV�QRW�GHÀQHG�E\�D�VHQVH�RI �VHFXULW\��WKHUH�LV�
greater likelihood for psychopathology, dysfunction, 
and distress. For preoccupied individuals, intense 
anxiety, hyperactivation, and defense mechanisms are 
maintained in order to combat feelings of  insecurity 
and psychological distress that has resulted from in-
security in early attachment experiences (Bachelor et 
al., 2010; Smith et al., 2009). Most likely, as children 
their caregivers were unpredictable leading them to 
develop neuroceptions of  potential danger, as well 
as create contradictory internal representations of  
the caregiver (Badenoch, 2008). The disintegration 
characterizing their childhood experiences results in 
disruptions in the brain’s neural networks, bringing 

about emotional dysregulation and an overwhelming 
energy that blinds the individual from forming rea-
sonable and objective perceptions (Badenoch, 2008). 
Badenoch (2008) terms the preoccupied individual’s 
internal world an “emotional jungle” (p. 70).  With 
regards to relating with others, the mental models 
guiding them lead them to expect they will have jag-
ged and unreliable relationships (Badenoch, 2008). 
 They exaggerate their personal distress and have 
an overwhelming need for the support and closeness 
of  others (Bernier et al., 2002; Dozier et al., 1995; 
Main et al., 1998). Their state of  mind typically con-
sists of  enmeshment in past and current relation-
ships, as well as confused feelings, possibly anger 
or fear, toward relationships (Atkinson et al., 2004; 
Badenoch, 2008; Bernier et al., 2002). An AAI nar-
rative would consist of  continuous interchanges of  
past and present experiences that are tangled together 
in a confusing disintegrated web, representing a poor 
sense of  self  (Badenoch, 2008). Their narratives may 
be extremely lengthy, with the clients becoming so 
caught up in their memories that it seems as if  they 
are reliving past experiences (Atkinson et al., 2004).
 At the onset of  therapy, preoccupied clients are 
more likely to have high anxiety and distress, and they 
often ruminate about what the therapist and others 
may have said (Atkinson et al., 2004; Mikulincer et al., 
2007; Shilkret, 2005; Smith et al., 2009). They are of-
ten concerned with the availability of  the therapist and 
want to be emotionally and physically close (Mikulinc-
er et al., 2007; Smith et al., 2009). The chaotic swap-
ping, lack of  coherency, and anxiety the patient brings 
to therapy can even make the clinician a bit anxious 
(Badenoch, 2008). In this case, it is important that the 
therapist be mindful and remain calm, as simply the 
presence of  the therapist’s calmness can promote the 
patterning of  emotion regulation (Badenoch, 2008). 

The Dismissing Patient
  Dismissing individuals, by contrast, tend to 
PLQLPL]H� WKH� VLJQLÀFDQFH� RI � HDUO\� DWWDFKPHQWV� DQG�
believe relationships are relatively unimportant (At-
kinson et al., 2004; Badenoch, 2008; Bernier et al., 
2002; Mikulincer et al., 2007; Muller, 2009; Zilcha et 
DO����������7KHVH�SDWLHQWV�KDYH�GLIÀFXOW\�HQJDJLQJ�LQ�
discussion regarding the inadequacy of  their early at-

FARRELL, CARLETON



110

tachment relationships, and, thus deny their feelings 
about these issues (Atkinson et al., 2004; Mikulincer 
et al., 2007; Muller, 2009; Zilcha et al., 2011). Even 
traumatic events will be minimized into an occur-
rence that is more socially accepted (Muller, 2009). 
Applying the role of  imagination proposed by Bono-
vitz (2012), these individuals may overly use fanta-
sy to avoid facing reality, resulting in rigidity in life 
and trouble in interpersonal relations (Bonovitz, 
2012). Due to their insistence on self-reliance and 
VHSDUDWHQHVV��WKH\�KDYH�GLIÀFXOW\�IRUPLQJ�ERQGV�DQG�
they reject or deny attachment needs (Bernier et al., 
2002; Dozier, 2004; Eagle, 2006; Main et al., 1998; 
Mikulincer et al., 2007; Muller, 2009, 2007; Shorey 
et al., 2006; Smith et al., 2009; Zilcha et al., 2011).
 The discourse of  dismissing patients’ narratives 
PD\�EH�ÁXHQW�� \HW� VHHPV� WR�EH�YHU\� VXSHUÀFLDO� DQG�
lack details (Badenoch, 2008; Bernier et al., 2002; 
Dozier et al., 2004). There is either dissociation or 
absence of  many aspects of  early attachment expe-
riences and emotional numbness as well (Bernier et 
al., 2002; Muller, 2009). Badenoch (2008) describes 
the mental model of  a dismissing patient as an “emo-
tional desert” (p. 68). The patient may describe their 
parents as “nice” or the relationship as “good” (Bad-
enoch, 2008). When listening to these narratives, cli-
nicians may struggle to grasp the internal model and 
community directing the patient’s mind (Badenoch, 
2008). Patients may convey cues that the therapist 
should not probe discussion on a certain topic or in-
trude in areas of  their life that they insist are not trou-
bling (Dozier et al., 2004). When treating a dismiss-
ing patient, there may be a challenge in creating an 
interpersonal connection, especially since dismissing 
individuals often lack the ability to read others’ sig-
nals (Badenoch, 2008). A particular obstacle to a ther-
apist’s relationship with a dismissing client is “mutual 
avoidance” (Muller, 2009). The patient’s ambiguous 
feelings toward a trauma or attachment relationship 
lead the therapist to question how to react; therefore, 
the therapist surrenders to the patient’s pull to avoid 
the topic (Bernier et al., 2002; Muller, 2009). Muller 
(2009) suggests, “The challenge in treatment, then, is 
LQ�KHOSLQJ�VXFK�SDWLHQWV�ÀQG�D�ZD\�WR�WHOO�D�VWRU\�WRR�
painful to speak, but too compelling to ignore” (pp.79).

The Unresolved Patient
 Similarly, those with unresolved attachment styles 
often lack recollections of  important experiences re-
lating to attachment in childhood (Dozier et al., 2004). 
They are so overwhelmed by the loss or trauma they 
experienced that they may have a lapse in reasoning 
(e.g., refusing to believe a person is dead), discourse, 
and behavior (Dozier et al., 2004). These individuals 
are even more disorganized in their cognitions and 
behaviors due to the inability to resolve early trau-
mas in attachment (Bernier et al., 2002). Their inner 
worlds are fragmented, consisting of  both chaos and 
rigidity (Badenoch, 2008).  The disorganization that 
characterizes the unresolved pattern of  attachment 
is demonstrated when these patients discuss ear-
ly attachment experiences and current relationships 
(Shilkret, 2005). Not surprisingly, individuals with un-
resolved attachments are more likely than others to 
be found in a psychiatric setting (Dozier et al., 2004).
 While relaying their narratives, unresolved-at-
tached patients’ speech may appear disorganized in, 
for example, the use of  incorrect tenses (e.g., using 
the present tense when speaking about the past), long 
SDXVHV��DQG�LQDELOLW\�WR�ÀQG�RQH·V�ZRUGV��%DGHQRFK��
2008). During the course of  therapy, they may pres-
ent as one of  the other attachment styles at different 
times, as they sporadically vary in the symptoms they 
are suffering from and their affective states (Shilkret, 
2005). Lamagna (in press) describes this common 
manifestation as “come close/stay away” messages 
(p.8). The patient’s lack of  coherency in discourse 
and behavior can cause a therapist to feel unstable 
and confused (Badenoch, 2008). Therapy with pa-
tients characterized by the unresolved attachment 
VW\OH�LV�ÀOOHG�ZLWK�FRQIXVLRQ��WKHUHIRUH��WKH�WKHUDSLVW�
must strive to maintain calmness and clarity (Shilkret, 
2005). Additionally, it is important to mention that 
these patients often come to therapy feeling ashamed 
about hurting those they loved with their unmanage-
able behaviors (Badenoch, 2008). For this reason, 
the beginning of  therapy must consist of  the ther-

1 Some theorists hold that those with unresolved attachments always 
can be diagnosed with an additional attachment pattern simulta-
neously (Main & Solomon, 1986; Badenoch, 2008).  For example, 
a patient may have a secure attachment to his father, while hav-
ing an unresolved attachment with his mother (Badenoch, 2008).

ATTACHMENT IN PSYCHOTHERAPY



111

apist making a purposeful effort to provide patients 
with a sense of  empathy, as well as emphasize the 
patients’ ability to change the dissociated mental 
models that led to regretful actions (Badenoch, 2008).

The Therapist’s Attachment Style

 Of  tantamount importance to the therapeutic en-
deavor is the therapist’s attachment style (Meyer et al., 
2001).  Just like any other individual, the therapist pos-
sesses his or her own internal working models and at-
tachment patterns (Bennett, 2008). In order for treat-
PHQW� WR�EH�HIÀFDFLRXV�� WKH� WKHUDSLVW�PXVW�EH�DZDUH�
of  his or her attachment style due to its large impact 
on one’s interpersonal competencies and disposition, 
and, thus, the client’s experience of  the therapist and 
vice versa (Atkinson et al., 2004; Bennett, 2008; Wal-
lin, 2007). The internal working models of  therapists 
affect their patterns of  self-protection, their ability to 
EH� VHOI�UHÁHFWLYH�� WKHLU� FDSDFLW\� IRU� FDUHJLYLQJ� �HP-
pathy), their proclivity for empathic understanding 
and their range of  affect regulation (Bennett, 2008).  
 Cortina and Marrone (2003) suggest four import-
DQW� IDFWRUV� LQÁXHQFLQJ� WKH�TXDOLW\�RI � WKH� WKHUDSLVW·V�
empathetic understanding, which include: his/her 
own early attachment history, his/her own experienc-
es as an analysand (client), his/her own experiences 
in clinical supervision, and his/her theoretical frame-
work or biases. As a clinician, one needs to mental-
ize during sessions with patients in order to separate 
his or her feelings and experiences from those of  the 
patient, while simultaneously recognizing the mental 
states of  the patient (Bateman et al., 2003). When in-
WHUDFWLRQV�SURYRNH�XQFRQVFLRXV�FRQÁLFWV�DQG�ZLVKHV�
in the therapist, it is possible for defense mechanisms 
to become mobilized and uncomfortable counter-
transference to occur (Bateman et al., 2003).  The 
phenomenon of  countertransference involves the 
changes in the therapist’s state of  mind and automat-
ic verbal/nonverbal behaviors that the patient picks 
up, causing either the exacerbation or alleviation of  
anxiety and other symptoms (Pally, 2001). Counter-
transference may occur due to the therapist’s need to 
be guarded from the patient’s transference, resulting 
in a distancing in the relationship; or there can be an 
activation of  automatic internal responses in the ther-

apist, causing him or her to involuntarily react with-
out thinking (Pally, 2001). All of  these occurrences 
can hinder the therapist’s capacity to be empathetic, 
the quality of  his/her technical skills, and the capac-
ity for affect attunement (Mallinckrodt, 2010). These 
HOHPHQWV�KDYH�DQ� LQÁXHQFH�RQ�WKH�WUHDWPHQW�FRQGL-
tions and outcome, as well as the therapeutic rela-
tionship (Meyer et al., 2001; Pally, 2001; Sable, 2007). 

Securely- Attached Therapists
 Therapists who are securely attached typical-
ly exhibit behaviors consistent with this attachment 
style, such as warmth and trustworthiness, which 
DUH� EHQHÀFLDO� IRU� GHYHORSLQJ� UHODWLRQVKLSV� �2EHJL��
2008). These secure attachment representations pro-
YLGH�WKH�WKHUDSLVW�ZLWK�JUHDWHU�ÁH[LELOLW\��VWDELOLW\��DQG�
DXWRQRP\�ZKHQ� LQ�GLIÀFXOW� LQWHUSHUVRQDO� VLWXDWLRQV��
VXFK� DV� DQ� XQFRPIRUWDEOH� ÀJKW� ZLWK� D� SDWLHQW� DQG�
the inevitable ruptures in the therapeutic relation-
ship (Lopez & Brennan, 2000; Meyer, 2001). Instead 
of  acting on one’s own attachment related fears and 
needs, the therapist can adapt his or her behaviors 
to suit the needs of  the patient involved in the inter-
SHUVRQDO�GLIÀFXOW\�� DIIRUGLQJ�EHWWHU� FDUH� IRU� WKH�SD-
tient (Cortina et al., 2003; Schauenburg et al., 2010). 
The study by Schauenburg et al (2010) focused on 
WKH� LQÁXHQFH� RI � WKHUDSLVWV·� DWWDFKPHQW� UHSUHVHQWD-
WLRQV� RQ� WKH� DOOLDQFH� DQG� FRQÀUPHG� WKH� EHQHÀFLDO�
effect of  therapists’ attachment security on the work-
ing alliance with interpersonally distressed patients.

Insecurely- Attached Therapists
 Conversely, therapists with an insecure attach-
ment style, such as dismissing or preoccupied, may 
KDYH�GLIÀFXOW\�ZKHQ�LW�FRPHV�WR�ZRUNLQJ�WKURXJK�DQG�
dealing with ruptures given the anxiety and fear of  re-
jection that constitute these attachment styles (Meyer 
et al., 2001). Their insecure attachment needs may 
also lead to substandard intervention strategies and 
DQ�LQDELOLW\�WR�EH�VHOI�UHÁHFWLYH��%HQQHWW���������'XH�
WR�WKH�ODFN�RI �UHÁHFWLRQ�LQ� LQVHFXUHO\�DWWDFKHG�WKHU-
apists, they may struggle with the regulation of  their 
own affect; therefore, they lack the ability to facili-
tate affect regulation in the patient, a critical healing 
element in the therapeutic process (Bennett, 2008). 
Given that therapist attachment style predicts aspects 

FARRELL, CARLETON



112

of  countertransference, therapists with dismissive at-
WDFKPHQW�PD\�EH�PRUH�GLVWDQW�ZLWK�GLIÀFXOW�SDWLHQWV�
and situations, as well as have more antagonistic coun-
tertransference reactions to patients (Bennett, 2008). 
Those with preoccupied attachment style might fear 
they are inadequate and struggle to separate their own 
anxieties and emotions from those of  the patient 
�%DWHPDQ�HW�DO���������%HQQHWW���������7KHVH�ÀQGLQJV�
suggest that the therapist’s attachment style interacts 
with the client’s attachment style to determine trans-
ference and countertransferences, the interpersonal 
experience, and, most importantly, the building and 
strength of  therapeutic relationship (Bennett, 2008).

Interaction Of  Therapist and Client Attachment 
Styles  
 Taking into account the importance of  the at-
tachment style of  both clinicians and patients, it is 
not surprising that the interaction between the two 
styles weighs heavily on the therapeutic process. 
Some research has indicated the advantageous effect 
of  similarities between the therapist and client re-
garding attitudes, personal beliefs and values, expec-
tations toward counseling, and self-concept  (Bernier 
et al., 2002). This would lead one to think that simi-
larity in attachment styles would be optimal for psy-
chotherapy (Bernier et al., 2002). However, interper-
sonal researchers and theorists suggest the presence 
of  both complementary and non-complementary 
exchanges is superior to the employment of  simply 
complementary or non-complementary stance (Ber-
nier et al., 2002). Although interpersonal theorists 
believe in the need for complementary exchanges, 
they are in agreement with attachment theorists and 
studies proposing the importance of  dissimilarities in 
the interpersonal facets of  client and therapist, and 
the notion that noncomplementary attachment styles 
are optimal for treatment (Bernier et al., 2002). If  
the therapist reinforces the client’s rigid expectations 
and/or replicates the aspects of  the client’s poor 
early attachment experiences in therapy, it can pos-
sible re-traumatize the patient (Cortina et al., 2003).
� %RZOE\� ������� VXJJHVWV� WKDW� WKH� WKHUDSLVW� ÁH[-
ibly adopt a contrasting stance that will challenge 
the client’s beliefs and rigid expectations about rela-
tionships (Bernier et al., 2002). Dismissing patients 

are prone to using defensive deactivation (active in-
hibition of  attachment-related material). Therapists 
need to challenge the client’s defensive strategy be-
cause this coping mechanism will only save the pa-
tient from distress for a short time and will eventually 
fail (Muller, 2009). According to Cortina & Marrone 
�������� GLVFRQÀUPLQJ� WKH� LQWHUQDO� ZRUNLQJ� PRGHOV�
of  dismissing (avoidant) patients’ is easier than doing 
the same for preoccupied patients. Whereas avoid-
DQW� LQGLYLGXDOV·� SULPDU\� DWWDFKPHQW� ÀJXUHV� ZHUH�
unresponsive, preoccupied individuals experienced 
inconsistency in their primary attachments (Cortina 
et al., 2003; Smith et al., 2009). As discussed before, 
the capacity of  the therapist to carry out this adap-
tation depends on his or her attachment style, with 
securely-attached therapists being the most adaptable 
(Bernier et al., 2002). The therapist’s resistance to 
naturally respond to the patient’s attachment tenden-
cies in a conforming manner can facilitate emotion-
al change and growth within the patient (a correc-
tive experience) (Bernier et al., 2002; Bowlby, 1980). 
 For example, a dismissive client may avoid spe-
FLÀF� WRSLFV� FRQWDLQLQJ� GHHS� HPRWLRQDO� FRQWHQW�� ,Q-
stead of  courteously following the patient’s attempt 
to focus on nonthreatening issues, the therapist needs 
to carefully challenge the client’s strategies and pro-
mote the gradual exploration of  the more intimate 
LVVXHV�WKH�FOLHQW�WULHV�WR�VKURXG�ZLWK�VXSHUÀFLDO�FRQ-
versation (Bernier et al., 2002; Dozier et al., 1998). 
On the other hand, excessively emotional or preoccu-
pied patients may require interventions encouraging 
the control of  emotions and autonomy (Bernier et 
al., 2002; Meyer et al., 2001). Hence, corrective ex-
periences are facilitated by matching therapist with 
patient based on dissimilar deactivating (avoidance) 
versus hyperactivating (clinging) dimensions of  at-
tachment (Bernier et al., 2002; Tyrell et al., 1999). 
One study reported by Tyrell et al (1999) found that 
preoccupied therapists formed the strongest alliance 
with dismissing patients and vice versa (Bernier et al., 
2002). Undoubtedly, the interaction of  attachment 
styles in psychotherapy is impactful on the transfor-
mation of  patient’s maladaptive thoughts and behav-
iors and the formation of  the therapeutic alliance. 
 In addition to the impact of  the therapist’s at-
tachment style, the style of  interpretation a therapist 

ATTACHMENT IN PSYCHOTHERAPY



113

uses also has implications in psychotherapy (Cortina 
et al., 2003). Even in the context of  a strong ther-
apeutic relationship, certain types of  interpretations 
FDQ�KDYH�D�QHJDWLYH�LQÁXHQFH��VXFK�DV�GHFRQWH[WXDO-
ization and double binding (Cortina et al., 2003). De-
contextualization refers to placing too much empha-
sis on the patients’ unconscious feelings and internal 
mechanisms (Cortina et al., 2003). Consequently, the 
therapist undervalues the patients’ subjective feel-
ings and the effects of  the external world (Cortina 
et al., 2003). The other counterproductive interpre-
tation, double binding, for example occurs when the 
therapist unintentionally instigates a feeling in the 
patient (e.g., makes the patient feel guilty) and then 
interprets that the patient possesses a guilt-ridden in-
ternal world (Cortina et al., 2003). Using attachment 
theory as a guide, the issues of  decontextualization 
and double binding are less likely to occur in the 
psychotherapeutic process given the theory’s strong 
emphasis on the external world’s role in develop-
ment (Cortina et al., 2003). By taking into account 
the internal and external worlds of  patients, the pa-
tient is less likely to feel he or she is being blamed, 
which would impair progress in psychotherapy. 

Conclusion and Summary

  Attachment theory describes the instinctive 
style of  individuals seeking proximity or protection 
when feeling threatened.  Further, it suggests ways 
in which attachment behavior is affected by envi-
ronmental factors (Bowlby, 1980; Sable, 2007). Re-
search in attachment theory following John Bowlby 
has given clinicians a compelling reason to explore 
the actual events and relationships in a patient’s early 
development, as well as the patient’s distinct interpre-
tations and representations of  experiences (Eagle et 
al., 2009). Early adverse experiences with attachment 
internalized by the receptive infant can impede the 
development of  psychological structures that favor 
resilience; therefore, the infant’s vulnerability to the 
emergence of  psychopathology is heightened (Sable, 
2007). It is suggested that, although an individual’s 
attachment style in infancy may be different from that 
of  adulthood, a child’s internal working model strong-
O\� LQÁXHQFHV� VXEVHTXHQW� EHKDYLRU�� DIIHFWV� WKH� ZD\�

others treat them, and, thus, affects their likelihood 
to suffer from psychopathology (Carlson, 1998 para-
phrased from Snyder & Shorey, 2006; Harris, 2004).
 Undoubtedly, it is the internalization of  these 
negative early experiences that generate negative in-
ternal working models (Harris, 2004; Levy, 2000; Wal-
lin, 2007). With their strong impact on how one car-
ries out his or her life, internal working models may 
give the impression of  being irreversible and resolute 
�:DOOLQ����������$OWKRXJK�WKH\�KDYH�D�VWURQJ�LQÁXHQFH�
on personality and interpersonal interactions, internal 
working models and one’s attachment state of  mind 
DUH�RSHQ�WR�PRGLÀFDWLRQV�E\�PHDQV�RI �QHZ�H[SHUL-
ences and relationships, with psychotherapy being a 
useful modality for positive transformation (Berni-
er et al., 2002; Wallin, 2007).  Individuals with mal-
adaptive attachment styles may have impairments in 
critical psychological processes; such as intersubjec-
tive relatedness, affect regulation, and mentalization 
(Bateman et al., 2003).  Such dysfunctions can expose 
an individual to psychological, physical, and/or social 
distress. Key goals of  psychotherapeutic treatment 
using attachment theory involve aiding the patient in: 
identifying unresolved emotions and appropriately 
expressing affect, developing stable internal repre-
sentations of  self  and others, constructing a secure 
and coherent sense of  self, and acquiring interper-
sonal characteristics that promote the potential for 
positive relationships (Bateman et al., 2003; Holmes, 
1995). Internal working models can be revised as 
G\VIXQFWLRQDO�UHSUHVHQWDWLRQV�DUH�FKDOOHQJHG��UHÁHFW-
ed on, and transformed (McCluskey, 1999; Zilcha et 
al., 2011). Bowlby (1980) asserted that clients must 
comprehend how their working models cause their 
unhealthy thoughts and behaviors in order for these 
models to be revised (Zilcha et al., 2011). The reorga-
QL]DWLRQ�RI �WKHVH�LQÁH[LEOH�LQWHUQDO�ZRUNLQJ�PRGHOV�
and the therapeutic relationship allows for psycholog-
ical processes, like affect-regulation, to be established, 
as well as new realistic views of  oneself  and others to 
be formed (Eagle et al., 2009; McCluskey et al., 1999).
 Attachment-informed psychotherapy has its ad-
vantages since it not only focuses on the history of  
early attachment experiences that led to the maladap-
tive attachment behaviors of  the patient in treatment, 
but also gives the therapist guidance in what approach 

FARRELL, CARLETON



114

to employ for a particular patient, illuminating an op-
timal trajectory of  treatment (Dolan et al., 1993; Har-
ris, 2004). With knowledge of  a patient’s attachment 
style, the therapist can be sensitive and adaptive to the 
patient’s needs, increasing and accelerating the chance 
IRU�H[SORUDWLRQ�DQG�EHQHÀFLDO�FKDQJH�WR�RFFXU��(DJOH�
et al., 2009). The therapist’s consistent understand-
ing from the start can enhance the experience of  the 
therapist as a secure base and strengthen the bond 
between the therapist and client, allowing the client 
to increase his or her exploration, and resolve the is-
sues involved (Eagle et al., 2009). In addition to the 
therapist’s support in confronting negative feelings 
and forming new models, the patient’s experience of  
a trustworthy and reliable other  (the therapist) is a 
healing element in itself  (Eagle et al., 2009; Obegi, 
2008). There is accumulating agreement that the qual-
ity of  the therapeutic alliance is one of  the strongest 
predictors of  psychotherapeutic outcome (Harris, 
2004; Horvath et al., 1991; Cortina & Marrone, 2003).
 Some have argued that attachment theory isn’t 
applicable to the practice of  psychotherapy (Farber 
et al., 1995). Hamilton (1987) believed attachment is 
a “background concept,” and “is all too palpable; we 
are surrounded by it; we can observe it; and yet, from 
a clinical point of  view, we cannot use it directly.” 
(p. 69). The relationship between attachment theory 
and psychotherapy may not now boast enough em-
pirical research for an explicit “attachment therapy” 
for adults, yet there continues to be growing evidence 
and innovative interventions supporting the bene-
ÀWV� RI � DSSO\LQJ� DWWDFKPHQW� WKHRU\� DQG� UHVHDUFK� WR�
the psychotherapeutic process (Eagle et al., 2009). 
As more studies are undertaken, the importance of  
attachment theory and its applicability to practice 
becomes better understood. Evidence suggests that 
attachment theory can enhance both the therapist’s 
and the adult patient’s awareness of  their roles in the 
psychotherapeutic process and therapeutic alliance. 
Additionally, attachment style it is a strong predic-
tor of  outcome for psychotherapy. Taken together, 
the strengths of  attachment theory suggest prom-
ising new directions for psychotherapy with adults.

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